Annual Report Form Agricultural Co-Operative Act Page 6

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SECTION C: Fees For Filing Annual Report

SECTION D: Signature Section

An officer of the association must sign this annual report.

__________________________________________________________________________________

NAME OF COMPANY

_________________________________

_____________________

___________

SIGNATURE

TITLE

DATE

THE FOLLOWING DOES NOT APPLY TO BUSINESSES WITH FEDERAL EMPLOYER IDENTIFICATION NUMBERS.

Pursuant to 5 Illinois Compiled Statutes 100/10-65(c), applications for renewal of a license or a new license shall include the applicant's Social Security

Number, and the applicant shall certify, under penalty of perjury, that he or she is not more than 30 days delinquent in complying with a child support

order. Failure to certify shall result in disciplinary action, and making a false statement may subject the applicant to contempt of court.

Are you more than 30 days delinquent in complying with a child support order?

Yes

(NOTE: If you are not subject to a child support order, answer "no.")

Applicant's Social Security Number is __________________________.

Under penalties of perjury, I declare that I have examined the application and all supporting documents submitted by me in connection therewith, and

to the best of my knowledge, they are true, correct, and complete.

___________________________________________

____________________________

Signature of Applicant

Date

NOTICE: This state agency is requesting disclosure of information that is necessary to accomplish the statutory purpose as outlined under Illinois